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PLAIDMAN

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I am new to PT coding/billing...we are billing our PT as incident to. I am having a difficult time determining dx. I have been using the dx that the physician has written on the order for PT. Is this correct?

example: doc wites PT for aftercare surgery TKA on the order , but the PT is writing in his notes osteoarthritis knee.....or loss of strength.

example: doc writes "spasms" on the order, but the PT is saying back pain....

I feel I should be following what the ordering doc wrote on the order?

any advice would be helpful, thanks
 
For rehab encounters you always use the V57.1 first-listed then you sue the reason for rehab. If the patient has had a knee replacement then it is osteoarthritis it is for the stiffness or instability being rehabbed so that is what you use secondary followed by the V code for joint replaced. If it is due to a fracture the you use the stiffness or atrophy secondary followed by the 905-909 code for late effect of fracture. It is wrong to use a dx code for a patient that no longer has that condition at the time of the encounter.
 
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